35 Misc. 3d 570
N.Y. Sup. Ct.2012Background
- Maimonides treated six patients with Medigap policies issued by First United between 2007 and 2011, with 365 lifetime days of coverage after Medicare exhaustions.
- Maimonides billed First United $19,075,525.90 and was paid $4,078,663.29 for these six patients.
- Plaintiff alleged six breach-of-contract claims, one for each patient, based on contracts and assigned benefits.
- Plaintiff also asserted six claims under Insurance Law § 3224-a (Prompt Pay Law) for failure to timely pay or notify of dispute, and a thirteenth claim for unjust enrichment.
- Defendant moved to dismiss the Prompt Pay Law claims (a/7) and the unjust enrichment claim (a/13) under CPLR 3211.
- Court considered whether the Prompt Pay Law provides an express or implied private right of action and whether unjust enrichment is duplicative.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Does Insurance Law § 3224-a create a private right of action? | Maimonides is within the statute’s intended beneficiaries and may sue directly. | No private right of action; enforcement is administrative via the Superintendent. | Yes; private right of action implied and maintained for providers. |
| Are the six Prompt Pay Law claims duplicative of contract claims? | Claims under § 3224-a are independent remedial rights, not duplicative. | Claims duplicate breach-of-contract rights and should be dismissed if contracts exist. | The claims proceed; not dismissed as duplicative. |
| Is the unjust enrichment claim viable alongside contract claims? | Unjust enrichment stands where contracts may not govern the dispute. | Unjust enrichment is duplicative where valid contracts exist. | Dismissed; contracts govern the matter. |
Key Cases Cited
- Matter of Polan v. State of N.Y. Ins. Dept., 3 N.Y.3d 54 (2004) (text supports private rights where statute grants individual benefits)
- Henry v. Isaac, 214 A.D.2d 188 (2d Dept 1995) (distinguishes remedial vs. individual rights in private actions)
- AHA Sales, Inc. v. Creative Bath Prods., Inc., 58 A.D.3d 6 (2d Dept 2008) (overruled Carrube on private rights where statutory scheme exists)
- Kofinas, 2008 NY Slip Op 32251(U) (N.Y. Mix) (discusses implied private rights; not binding authority here)
- Barzingus v. Wilheim, 306 F.3d 17 (10th Cir. 2010) (motion to compel arbitration standard similar to summary judgment)
- Majewski v. Broadalbin-Perth Cent. School Dist., 91 N.Y.2d 577 (1998) (legislative intent statements require cautious use)
- Carrier v. Salvation Army, 88 N.Y.2d 298 (1996) (extensive regulatory schemes may limit private action; context matters)
- Burns Jackson Miller Summit & Spitzer v. Lindner, 59 N.Y.2d 314 (1983) (statutory enforcement schemes and private action balance)
- Oxford Health Plans, Inc., 15 A.D.3d 206 (1st Dept 2005) (standing issue in private actions under Insurance Law § 3224-a)
- Klinger v. Allstate Ins. Co., 268 A.D.2d 562 (2d Dept 2000) (illustrates statutory enforcement vs. private rights)